Why I No Longer Practice Medicine In Ohio

I grew up on my grandparents’ farm in rural Ohio. After high school I worked in polymer factories for fifteen years because I wasn’t sure what I wanted to be when I grew up (!) but eventually I decided med school was the way to go (!!), and at the age of 32 I joined the Ohio Army National Guard for the GI Bill and started college.

I spent six years in the Guard as a cavalry scout and loved it. I reached the rank of sergeant and graduated Kent State with my BS (in Mathematics, in fact, but that’s a story for another day).

I was accepted into med school and started at Case Western Reserve School of Medicine on my thirty-eighth birthday. I switched branches to the Navy and they gave me a scholarship to pay my tuition, which was supplemented by a sizable grant from the Joseph Collins Foundation. Now I was a naval officer on Inactive Reserve. Med school was challenging, more so because I had a family in tow, but I made it through, got my MD in 2007 and started residency in Family Medicine. I had had a vision for myself from the beginning of this odyssey of being the ‘country doctor’.

After residency I shipped off to active duty with the Navy at the Marine Corps Air-Ground Combat Center in 29 Palms, and when that was done came back home and started working for a local hospital. We set up a clinic in the same town from which I had graduated high school, and for several years things were going well.

Then the pandemic hit and the clinic closed down. I struck out on my own as an independent doc at a small private clinic.

On June 9, 2021, the DEA raided the clinic and accused me of illegally prescribing opiates. Three years before, the State Medical Board of Ohio had asked me about my prescribing practices; I had answered their questions, provided them with records, and thought the issue was settled since nothing more was said. But the Fed heard about it, and ran with it.

I hired a lawyer and voluntarily gave up my DEA certificate. At first, I thought I had a good shot of defending myself. After all, they were saying that I had been handing out oxycodone without appropriate diagnoses and without regard for my patients’ health. At the time I had 1,127 patients in my care, of which all of 73 were on chronic pain management for things like Crohn’s Disease, Complex Regional Pain Syndrome, or Spinal Stenosis. I knew I had always been very particular about my documentation, and always had definite reasons for treatment and clear goals for my people in mind. These folks were functioning. They were holding down jobs, caring for their families, and had a decent quality of life. They had been seen by Physical Therapy, Aquatherapy, Orthopedics, Neurology, Neurosurgery, Psychology, Pain Management and Rheumatology. They were involved in acupuncture and were managed, not only on opiates, but neuropathics, NSAIDs and topical treatments. And I was not just ‘dabbling’ in pain management: I had done multiple rotations at the pain clinic at the Wade Park VA under the direct tutelage of one of the area’s top pain docs, and had also been taught one-on-one in end-of-life care for hospice patients (which often requires the concurrent use of opiates and benzodiazepines) by one of Ohio’s top geriatricians (who, by the way, offered me a job in 2022, though I had to turn him down because I didn’t want to try to get my DEA certificate back).

But by November 2021 it was clear to my attorney that things were not going to go well. His take was, I could take it to trial, but it would cost over a hundred thousand dollars and there was a very good chance I would still lose and go to prison for twenty years (you know what they say… you can’t fight city hall – and I was a lone, independent doctor against the Fed). I had been through a divorce in the past and knew from painful experience that court is nothing like it is on TV. It’s not a chess game where evidence and testimony jockey for position and the perp is backed into a corner from which he can’t escape, or the unjustly accused are exonerated when the truth is revealed. It’s intimidation, inflammatory language, and whether the court even feels like admitting the evidence you have.

The other option was to take a plea for health care fraud, to say that I had brought people in for unnecessary visits. Still a felony, still untrue, but much less likely to carry a prison sentence and no need for that six-figure court battle. What was I to do? I had a wife and ten-year-old son at home. I would have had to sell the house and pretty much everything else to go to trial, still lost, and then they would have been without support and homeless.

So, I took the plea. Twelve counts, for twelve visits. Out of seventy-odd folks over seven years. My conviction was formally entered on June 15, 2023, and I started 6 months of house arrest.

What amazed me about that part of the legal process is how little our judicial branch knows about the medical field. I was ostracized in the pre-sentencing report for ‘often prescribing well in excess of the CDC-recommended maximum of 90 morphine equivalents per day (90 MED)’. For a little context, in 2016 the CDC issued recommendations on opiate prescribing. That 90 MED dose was in fact a benchmark. It was not a hard limit. It was a point at which you were to ‘press pause’ and make sure you were doing the right things for the right reasons 1. (Fun fact: when you take a plea you get to write out your own confession! It’s called the ‘Acceptance of Responsibility Statement’ and it’s where you get to write in your own words how and why you did what it’s claimed you did. Because if you don’t, and you insist on protesting your innocence, you’ll get branded as unrepentant. And believe me, you don’t want that to happen.)

In the meantime, the Medical Board remembered me and took action against my license. I wasn’t terribly concerned at first. I had read their expert report and the allegations they made, and I had rebuttals for every point. It was stunning, really, their expert report itself: wrong dates of service, claims things weren’t done, which were clearly documented in the record, or conversely claims of statements made, that weren’t… at times I wondered if their expert had even read my patients’ charts, or had simply ctrl-F’d through the whole thing.

It should be noted at this point that the State Medical Board of Ohio had, on December 23, 2018, codified the CDC’s 2016 guidelines (with a grandfather clause for people already on doses of pain meds in excess of that 90 MED mark). It is also important to note that on April 24, 2019, the CDC itself released a paper warning against an overly-zealous application of what were only supposed to be guidelines, as ‘rules’ 2. They were beginning to see that med boards, hospital systems, and insurers across the country were interpreting their advice too rigidly and inappropriately cutting off patients’ meds, and in fact were quite possibly causing an increase in opiate deaths 3. I’m not going to speculate here as to why that was; other folks have already done that 4.

The hearing for my prescribing practices was set for late January 2024. Once the felony conviction took hold, though, the Med Board decided they now had a separate issue and held a hearing on September 25, 2023, for the conviction. At that hearing (done by videoconference) I tried to explain what I felt had happened, thinking that a group tasked with setting policy would be interested in knowing these things, but the prosecutor stated I was making excuses and showing no remorse. The Board then set a date for December 13, 2023, to make a formal decision.

Now let me paint you a picture: the State Medical Board of Ohio holds their meetings in what used to be the Ohio State Supreme Court courtroom, and they had specifically decided against any redecorating when they took over the space. There is an imposing raised dais seating the twelve board members, and twenty-foot ceilings. This makes you, standing alone on the floor before them, feel very small. My attorney and I had five minutes (conveniently counted down by a timer!) to make our final statements. We reminded them there were two cases before them, and the original case, for which we had my rebuttals, our own expert witnesses, and patient testimonies prepared, was due for hearing in six weeks. We asked simply that they take no action on my license that day but wait until January so we could present our defense.

The Board then deliberated. For all of five more minutes. One Board member asked the others if it would be such a bad thing to wait until the next hearing to see what we had, but that notion was quickly squashed. I had pled guilty to the health care fraud charge, it was argued, and that was enough. They ‘didn’t need to hear any more’ and I ‘did not deserve to be a physician in the State of Ohio’.

Again I was amazed at the cavalier attitude and apparent lack of real-world experience present. For example, I was criticized for expressing a lack of faith in pill counts as they could be easily faked. These meds are all stamped with codes, I was told, making it easy to see if the count has been ‘supplemented’.

Now let me take a moment to talk about pharmacies. They’re businesses, after all, and will buy their stock wherever they can get a good price. Oxycodone itself is available in the US from Veranova, Noramco, Chattem Chem, Siegfried USA, Mallinckroot Chem, and Penick Corp, and the 30mg dose alone comes in no less than eight different code/color/size combinations (per the Epocrates Drug Database):

Sometimes pharmacies will get their meds from one supplier, sometimes from another. Sometimes they won’t be able to give a patient a full script and will issue a partial fill and make up the balance when the next shipment comes in – from wherever. Sometimes patients will get their meds filled a few days early, because of a holiday weekend for example, and again, might be given a different looking pill that gets mixed in with the tail end of last months’ script. And don’t forget the folks on PRN meds, who may end up with a bottle in the car, one in their purse, and one at work, all getting filled at different rates. The point here is that, even a completely legitimate patient who is absolutely lockstep in taking their meds may end up with a mix of pills through no fault of their own. Was I then supposed to fail that patient’s pill count and cut them off, with all the potential dire consequences of such a course 5?

I also had only a certain amount of faith in urine drug screens. I did them, but I knew there is an entire industry out there to beat them. After all, it’s possible to pick up a kit at a store on your way to your doctor’s office for that surprise call-in that will fix your urine for you.

My solution was to see them. Often. To lay eyes on them, see how they acted, how they were dressed and groomed, how they answered questions, whether they made eye contact, who brought them, and how was that person acting in the waiting room? How were their vitals, and their physical exam? Were there inconsistencies in their histories? How were they doing? How was their pain? Was it controlled? What could we do to make it better, now, and long-term?

Was it a perfect method? Of course not. But I felt if someone was gaming the system it would be a lot harder to keep up appearances month after month than it would be to pick up a handful of pills off the street to refill a bottle. But this strategy, apparently, was tantamount to bringing patients in ‘unnecessarily’ and constituted ‘health care fraud’.

In any case, after just a few minutes a vote was held and my Ohio license was gone. I had had no chance to present my defense. I could appeal, sure, and spend another fifty thousand, but I had seen what I was dealing with and was not impressed that anyone was willing to listen.

The real kick in the teeth is that, not eight months after the DEA filed charges against me, the U.S. Supreme Court ruled in Ruan v. United States that the conviction of illegal prescribing required proving the physician acted 'knowingly or intentionally' in defiance of his patients' best interests.

Nevertheless, that, ladies and gentlemen, is why I no longer practice medicine in the State of Ohio.

References:

1.       Dowell D, Haegerich T, Chou R. 2016, March 15. CDC Guidelines for Prescribing Opioids for Chronic Pain – United States, 2016.  MMWR Recomm Rep 2016;65(No. RR6501e1er) (pp 1-50). https://www.cdc.gov/media/modules/dpk/2016/dpk-pod/rr6501e1er-ebook.pdf

2.       CDC Media Relations. 2019, April 24. CDC Advises Against Misapplication of the Guideline for Prescribing Opioids for Chronic Pain [Press Release]. https://archive.cdc.gov/#/details?url=https://www.cdc.gov/media/releases/2019/s0424-advises-misapplication-guideline-prescribing-opioids.html

3.       Harm Reduction Ohio. 2022, October 17. First Projection of 2022: Overdose deaths on track to decline this year. https://www.harmreductionohio.org/overdose-death-on-track-to-decline-lightly-in-2022/

4.       Powell, Alvin. 2022, November 21. New CDC guidelines a ‘corrective’ for opioid prescriptions, specialist says. The Harvard Gazette.  https://news.harvard.edu/gazette/story/2022/11/new-cdc-guidelines-a-corrective-for-opioid-prescriptions-specialist-says/

5.       Kennedy M, Crabtree A, Nolan S, et al. 2022, December 1. Discontinuation and tapering of prescribed opioids and risk of overdose among people on long-term opioid therapy for pain with and without opioid use disorder in British Columbia: a retrospective cohort study. PLOS Medicine. https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004123